Jolanda Dwarswaard

institute of Health, Policy and Management &

Department of Medical Ethics and Philosophy

Erasmus University Rotterdam

j.dwarswaard@erasmusmc.nl

Paper to be presented at the ECPR-Workshop “Changing forms of management and governing of

national health care in Europe: towards new roles for the state?” Helsinki May 2007

Dutch Health Care Reform and Medical Professional Ethics:

A Plural Picture of the Good Doctor

Draft. Comments are welcome. Please do not quote without permission.

Abstract

The paper examines the influence of health care reform on medical professional ethics. In order to illustrate this influence two cases are discussed. Bases on these cases, I question whether the government deliberately aimed at changing the medical professional ethics. An analysis of authoritative policy documents shows that the government requires doctors to perform three roles: the statesman, the businessman and the professional. The ethical dilemmas that follow from the combination of these three roles are ignored in the policy documents. In the paper possible causes of this neglect are discussed. In the second part of the paper the reaction of the Dutch Royal Medical Association (KNMG) on the new health care system is assessed.

Introduction

Individual doctors are expected to act in accordance with ethical principles that are shared by the

whole medical profession. National as well as international medical professional organizations

publish ethical codes and guidelines to inform doctors and society about the norms and values

that should guide the behaviour of a good doctor. The term ‘medical professional ethics’ is used

to refer to this set of norms and values. Medical professional ethics is not static, but is changing

over time. In several respects the medical ethical guidelines published by the Dutch Royal

Medical Association (KNMG) in 1936 and the current document that discusses the rules of

behaviour, adjusted in 2002, are different (NMG 1936, KNMG 2002). Several developments can

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contribute to these changes in medical professional ethics. In this paper the influence of health

care policy on the norms and values of the medical profession will be assessed.

The Dutch government has introduced a new health care system, based on managed competition,

in January 2006. The reform is supposed to lead to an efficient and affordable health care system,

also in the long term. In order to realize these goals, a private system is combined with limiting

conditions set by the government (VWS 2006). The new health care system has important

implications for the role of the different actors in the health care field. These new roles may also

affect the norms and values that are cherished by the doctor. In order to act in accordance with

the new health care policy, the traditional set of medical ethical values will inevitably change, or

has to be changed or adjusted by the medical profession. By shaping the context in which doctors

perform their daily work, policy making can be seen as an attempt to change people’s behaviour

(Abma & In ‘t Veld 2001). Stone describes this influence as follows ‘Each model of social

regulation draws lines around what people may and may not do and how they may or may not

treat ach other’ (Stone 2002:13). Consequently, characteristics of social regulation demonstrate

how people are expected to behave. In this paper we discuss the government’s perception of a

good doctor. In other words, which picture of a good doctor does the Dutch government draw? In

addition, it is interesting to investigate how the Dutch Royal Medical Association (KNMG), as a

representative body of the doctors who perform their daily work in the new circumstances,

reacted on the introduction of the new health care system. Did they agree with the government

about the characteristics of a good doctor? Or did they raise important objections against the

picture that is drawn by the government? These questions are especially relevant because some

of the new expectations are at variance with the old medical professional values. In order to

show that some of the new norms are at odds with old norms two cases will be introduced. These

cases concern norms that are challenged by the new health care system. The new system requires

doctors to change two medical professional principles: (1) doctors ration care on the basis of

medical need and (2) doctors do not advertise their own services.

The investigation is based on an analysis of authoritative policy documents. This implies that we

do not discuss what is actually occurring in practice. Accordingly, we do not deal with how

doctors incorporate the new values and norms. I investigate which values and norms are written

down and how they may change the traditional medical professional values. Policy texts and

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coalition agreements are scrutinized to investigate what the government expects of doctors. I do

not expect that these documents contain a full and explicit description of the characteristics of a

good doctor. However, the steering mechanisms that are chosen will express implicit

expectations concerning the behavior of doctors.

Policy documents of the last twenty years are studied, because the Dutch reform towards

regulated competition in health care was an incremental process in which several technical and

institutional adjustments have taken place (Helderman et al 2005). The report of the Dekker

Committee in 1987 was the first step towards more competition in health care. Hence, the

analysis of policy texts and coalition agreements starts in 1986, because the cabinet that

established the Dekker Committee was installed in that period. To analyse the reaction of the

medical professional organization, documents of the KNMG concerning the new health care

system are studied. Table 1 and 2 of the annex give an overview of the analysed documents.

A new division of roles

The relation between the medical profession and society is changing. Traditionally, the medical

profession had the exclusive right to define and adjust medical professional ethics. The medical

profession was entitled by society to define the characteristics of good medical care and a good

doctor. The professional status of doctors gave them a special position of trust in society. The

government expressed this trust by granting the medical profession a monopoly on defining and

providing care. In the so-called ‘golden age of medicine’ doctors were taken to be the only

expert in the field of health care. The government did not interfere with the provision of health

care. Nowadays, the government wants to have a stake in defining good medical care and the

characteristics of a good doctor (Schnabel 1988, McKinlay & Marceau 2002). Although

traditionally the Dutch government do not provide care1 they shape the situation in which private

actors perform their task. The main instrument the government can use for this purpose is the

design of the health care system. Recently, a major reform has taken place in the Netherlands.

This reform fits in the international trend towards the use of market incentives in the health care

system (Cutler 2002). The essence of the Dutch new health care system is a change from a

‘supply driven system’ towards ‘managed competition’. To reach this goal the government

1 Historically this is delegated to private providers and insurers.

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overhauled the steering of the health care system and introduced a basic insurance. The basic

insurance replaces the old system in which a distinction was made between private insurance and

Sickness Funds. People who earned less than a certain income ceiling were obligated to insure

themselves at Sickness Funds. People who earned more than the income ceiling were not

obligated to have insurance (Boot & Knapen 2005). In the new health care system every citizen

is obligated to have insurance and insurers are obligated to accept every citizens for the basic

package (VWS 2006).

The new ‘demand driven’ Dutch health care system is based on managed competition and

replaces the old ‘supply driven system’ which was considered to have some major shortcomings.

In the old ‘supply driven system’ health care providers, insurers and patients were strongly

regulated by the government. From the 1970s government regulation increased, because of the

rising health care costs. The government tried to control costs by regulation of prices and

capacity of the health care sector. The Hospital Provision Act2 regulated the hospital capacity

and the Health Care Tariffs Act3 regulated the tariffs of services. By means of these laws the

government steered the supply of the health care sector (Boot & Knapen 2005). According to the

government this system offered only limited choice to patients, it led to inadequate coordination

between different health care providers and services, and to a poor match between supply and

demand. Besides the poor demand-focus there were also limited possibilities for

entrepreneurship, flexibility and innovation. Finally, the government mentioned the lack of

efficiency and transparency in the provision of health care as a reason to introduce managed

competition (VWS 2006). Managed competition was introduced as the solution to these

problems.

In order to reach competition an overhaul in the steering of the health care system was

considered to be necessary. The new steering mechanisms amount to a new division of

responsibilities of the actors involved. Providing patients with more choice should strengthen

their role. Insurers are instructed to become a trustee of the interest of their clients, which means

that they have to purchase high quality care and have to provide information about that quality of

2 Wet Ziekenhuisvoorzieningen (WZV) 3 Wet Tarieven Gezondheidszorg (WTG)

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care in order to facilitate a well-informed choice. Doctors also have to give insight in the quality

of care they provide. In their new role they have to compete with each other on the basis of price

and quality of delivered care in order to be contracted to the insurance companies. As trustee of

their clients insurers have to contract health care providers that provide efficient and high quality

care. In the old system insurance companies were obligated to make an agreement with every

health care provider4. The abolishment of this obligation in the new system stimulates

competition between health care providers.

Introducing two cases

As already mentioned in the introduction, the new division of responsibilities may have some

important implications for medical professional ethics. In this section I will introduce two cases

to illustrate possible influence of health care policy on medical professional ethics. Both of these

norms were part of the Dutch medical ethical guidelines until the introduction of the new health

care system. On the international level these principles are supported as well. For both principles

are part of the Declaration of Geneva. This modern version of the Hippocratic Oath was adopted

shortly after the Second World War and recently confirmed by the General Assembly of World

Medical Association (WMA 2006).

The first ‘old’ norm that may be challenged by the new health care system concerns the

prohibition of doctors to advertise their own services. This norm follows from the medical

professional principle that doctors are not supposed to be rivals, but colleagues. In the

Declaration of Geneva this is stated as follows: ‘My colleagues will be my brothers and sisters’

and ‘I will not undermine the patient-physician relationship of colleagues in order to attract

patients’ (WMA 2006). A prohibition for doctors to draw attention to their services was part of

Dutch medical ethical guidelines until 2002. In the ethical guidelines of 1959 this was stated as

follows: We first mention advertising. We have to emphasize that a doctor acts against the most

important principles of medical professional ethics when he draws public attention to his

services (KNMG 1959:34; translated from Dutch).

4 The obligation to contract individual health care providers was abolished in 1992 (van de Gronden 2001).

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The ethical guidelines of the KNMG were adapted in 1983, 1993 and 2002. Until 2002 the

prohibition to advertise was mentioned in the ethical guidelines as follows: ‘A doctor is

prohibited to advertises his services in order to canvass costumers (KNMG 1993:1283;

translated from Dutch). Generally, advertising was considered to be in conflict with the dignity

of the profession. More specifically, the reason for prohibiting advertising was twofold. Firstly,

the provision of health care was not considered to be a trade transaction. Advertising is aimed at

making profit, which undermines the relation of trust that is necessary between doctors and

patients. Secondly, advertising was associated with deceit, which was considered to have more

serious consequences in health care than in other sectors, because it affects the health of people

(KNMG 2003).

In the adjusted medical ethical guidelines of 2002 this norm has been removed. Forced by

competition law the KNMG had to delete the prohibition to advertise. The Dutch Competition

Law does not allow doctors to prohibit competition. Even before the new system was introduced

formally the Competition Law was applicable to the health care sector. The incremental changes

towards managed competition explain why this effect was already noticeable before January

2006. The new ethical guidelines state that publicity should be ‘factual, checkable and

understandable’ (KNMG 2002:6; translated from Dutch), but no longer prohibit advertising.

When members asked questions about this adjustment the KNMG declared that it did not mean

to promote advertising. The association still sees negative effects of advertising, but is not

allowed to force doctors to act according to its rules: If it is impossible for the KNMG to

formulate a rule of behaviour concerning advertising, she can still weigh the positive and

negative aspects of advertising and criticise advertisements that have negative effects on the

work of other doctors, or mislead the public, thereby endangering public health (KNMG 2003;

translated form Dutch). However, it remains unclear how the KNMG perform this task.

The second norm that is challenged by the new health care system concerns prioritising and

rationing of medical care. In the supply-driven system the government controlled costs, while in

the new demand-driven system cost containment has become a responsibility of insurers (VWS

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2006). According to the ‘old’ norm doctors ration health care in situations of scarcity on the

basis of medical need. Insurance conditions should play no role in the decision which patient to

treat first. The Code of Geneva depicts it as follows: ‘The health of my patient will be my first

consideration’ (WMA 2006). This principle is further discussed in the Declaration of the Right

of the Patient of the World Medical Association, which states: ‘In circumstances where a choice

must be made between potential patients for a particular treatment which is in limited supply, all

such patients are entitled to a fair selection procedure for that treatment. That choice must be

based on medical criteria and made without discrimination’ (WMA 2005:70). In the Netherlands

the medical ethical committee of the KNMG wrote a position paper about rationing care called

‘Selection of patients’. In this report the KNMG state that medical criteria should be the basis for

the decision. Medical criteria are specified as: the prediction of medical success, the gravity of

the disease, the general and physical condition of the patient and the degree of suffering (KNMG

1990:498). In 1992 this is stressed by the report of the Medical Ethics Committee about rationing

of health care (KNMG 1992). In 1999 the KNMG rejected a proposal of the then minister of

Health, Welfare and Sports to finance health care with private money, because: ‘it will be a

direct threat to the access of our health care system in which only medical criteria are supposed

to determine the decision who to treat first (KNMG 1999:939; translated from Dutch).

This principle is not only mentioned in ethical codes and position papers of the medical

professional organization, a majority in Dutch parliament considered medical need the right

criterion to distribute health care. This can be illustrated by a discussion about ‘business clinics’

in the 1990s. Employers established these clinics as a reaction on the long waiting lists for some

treatments. The aim of the clinics was to reduce waiting time for employees. Timely treatment

became important for employers, because new regulation increased the period in which they had

to pay sick employees (Brouwer et al 1998). The then Dutch minister of Health, Welfare and

Sports forbade these ‘business clinics’. In a letter to Parliament the minister said: ‘Whether

someone needs care, is based on indication. This indication should be based on medical criteria

as an objective criterion for the need of care’ (TK 1998:3; translated from Dutch). In 1998 a

motion about prioritising proposed by Marijnissen (Socialist Party) was accepted by a majority

in Parliament. The motion stated that medical care should be prioritised according to medical

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need. Only the VVD, a right-wing liberal party, and a small extreme-right party (CD) voted

against the motion (TK Handelingen pag. 4978-4984).

In the new health care system insurance companies have to contract health care providers. These

contracts can also contain an agreement about maximum waiting times. Timely treatment is

supposed to be one of the instruments the insurance companies can use to attract new clients.

Consequently, this may force doctors to prioritise patients on the basis of their insurance status

instead of their medical condition, thus jeopardising the ‘old’ norm to treat patient according to

medical need. The Dutch Federation of Patients and Consumer Organizations (NPCF) already

complained about this effect of the new system. A patient had to wait longer for a treatment,

because the local insurer had a contract with the hospital that arranged priority treatment for their

insured (NPCF 2006).

The new steering mechanisms seem to be a break in the ethical tradition of the Netherlands.

These two cases illustrate how health care policy changes and moulds the norms and values of

the medical profession. In order to understand whether the government deliberately aims at

changing medical professional ethics an overview of the characteristics of a good doctor

mentioned in the policy papers will be given.

The good doctor according to the policy documents

The policy documents are analyzed to see which picture of a good doctor the government draws.

This picture contains two elements. Firstly, the policy documents implicitly and explicitly reflect

on the characteristics of a doctor that are considered to be important by the government. Mostly,

the policy documents do not refer to doctors5. In that case, the characteristics of a good doctor

will be deduced from the policy goals. Secondly, the policy documents express assumptions of

policy makers concerning the motivation of doctors. These assumptions can be mentioned

explicitly, but more often they are ’implicit reflecting the unconscious values or unarticulated

beliefs of the policy-maker involved’ (Le Grand 2003:2). The assumptions about motivation refer

to the internal desires or preferences that incite action. Motivation is the reason why you act in a

5 This paper is concerned with the characteristics of doctor. However, policy documents mostly refer to health care providers instead of doctors. In what follows the language of the policy documents is used.

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certain way. According to Le Grand policy makers can have, broadly speaking, two distinctive

assumptions about human motivation. Either they consider actors to be knaves or they consider

them to knights. Knaves are agents who are motivated by self-interest. Self-interest relates to

many aspects. It can be focused on money, but autonomy, status, power and pleasure are also

incentives by which knaves can be motivated. Knights are motivated by altruism, which means

that they help people without a private reward. Important to note is that this distinction is not

based on the actual behaviour of agents. It refers to the assumption of policy makers about

human motivation (Le Grand 2003).

All policy documents refer to high quality care as the central aim of the new health care system.

Referring to this broad term other characteristics of the new system are mentioned. In order to

realise a health care system that provides high quality care several criteria have to be met.

Effectiveness is mentioned as an important aspect of good medical care. Consequently, providing

effective care is considered to be an important characteristic of a good doctor. The appeal to

effectiveness is based on the notion that cost containment is necessary in order to have a

sustainable health care system. Wisse Dekker, author of the first report in which the system of

managed competition was laid out in full, argues: ‘Many think that our health care system,

especially the insurance system, contains insufficient incentives to provide effective care. This is

attributed to lack of market mechanisms.’ (V2:8; translated from Dutch) In the coalition

agreement of 1998 the focus on effectiveness is phrased as follows: ‘All actors involved are

expected to use the collected premiums as effectively as possible. Several instruments – among

which budgeting and in some circumstances competition – are helpful tools.’ (V19:38; translated

from Dutch). Criteria for effectiveness need to be expressed in protocols and standards of the

medical profession. Clear norms and indicators should be developed to judge the effectiveness of

medical care (V11). The government does not trust doctors to provide effective care, because the

public can hardly control them. According to the policy documents doctors lack cost-

consciousness and create their own work: ‘In effect every doctor creates his own work, it is

assumed that not all services are necessary’ (V2:17; translated from Dutch). In subsequent

documents the government stresses this point: ‘The public can hardly control the medical

profession, this may result in supplier induced demand’ (V15:2; translated from Dutch).

Incentives are supposed to be necessary in order to stimulate doctors to provide effective care.

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The good care provider according to the government documents should be accountable. Care

providers should be open about the quality of care they provide. Accountability not only refers to

the quality of care. The doctor should also take the public good into account. The doctor should

be part of a social process and not only focus on his medical expertise. This needs to be

expressed in professional training. Besides medical expertise, doctors should have knowledge

about legal, ethical, social-physiological and economic issues. A general commitment to the

public at large should be an important characteristic (V6:42). In a letter to Parliament the

Minister says: ‘In the future healthcare insurers and providers have a central role in realising

general interest.’ (V14:3; translated from Dutch) The White Paper ‘Focus on demand’ also

emphasizes this commitment (V12). However, it remains unclear what this means on the

individual level: the relation between doctor and patient. It is problematic that no distinction is

made between the health care organization and the individual doctor who works within that

organization.

Another aspect of high quality of care should be a demand-driven focus. Health care should be

adapted to the wishes of the patient: ‘Health care providers deliver high quality care that has

been adapted to the to the wishes of the patient, as much as possible.’ (V12:32; translated from

Dutch) To reach this goal incentives are supposed to be necessary. Actions aimed at increasing

quality of care need to be provoked: The care provider or insurers needs to have a stake in the

quality of the delivered product’ (V2:79; translated from Dutch). In subsequent reports

incentives are deemed to be essential again: ‘health care insurers and health care providers

should have a substantial stake in the improvement of quality and effectiveness of care’ (V11:10;

translated from Dutch) and ‘better incentives should result in a better performance of the health

care system’ (V15:3; translated from Dutch).

Competition among health care providers and among insurers is regarded as a suitable incentive

to achieve demand-driven high quality health care. The role of health care insurers and

consumers should be strengthened to counterbalance the traditionally strong position of health

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care providers: ‘The position of the user of care in relation to the traditional dominant health

care provider will be strengthened.’ (V13:13; translated from Dutch). Insurers become

purchasers of care and have to contract with health care providers. It follows from their new role

that they can also make agreements about the quality of care and the organizational conditions of

the provision of care. Health care insurers and providers have a shared responsibility for the

quality of care. What this means in practice is not discussed.

The focus on competition reflects an important implicit value about good medical care. By

stressing the importance of competition the government also wants the doctors to distinguish

themselves form each other. Doctors have to be ‘attractive’ for insurers. They can only be

‘attractive’ for insurers if they show them, in terms of costs and / or quality of care delivered,

that they are different from other doctors. This implies that a good medical doctor is not only

open about the quality of care he or she delivers, but also has to sell himself. It means at least

that good medical professionals make clear what is distinctive about their ‘product’. The policy

papers never mention that doctors will be required to advertise their services, while they were

forbidden to do so in the past. This important ethical change is ignored altogether.

In spite of the talk about mechanisms and incentives, the government sometimes stresses the

importance of professionalism. The Dekker Committee stated that the highest quality of care is

reached by an appeal to professional honor. Intrinsically motivated and happy doctors are also

important for the government. From 1998 on this has been mentioned in subsequent coalition

agreements. The 1998 coalition agreement envisions: ‘motivated healthcare workers who are

satisfied by their work’ (V19:35; translated from Dutch). The image of the health care sector

needs to be restored in order to solve the shortage of healthcare workers. In 2002 work pleasure

is brought up in relation to high quality care: ‘Employees have to enjoy their work again in order

to increase their performance’ (V20:9; translated from Dutch). In 2003 motivation is related to

professionalism. ‘In health care patients’ and client’s demands should be paramount and

professionalism of health care workers should be emphasized’ (V21:8; translated from Dutch).

The 2007 Coalition Agreement also declares the importance of professionalism: ‘Therefore we

want to invest in patients and professionals support for the new health care system and work

together to diminish unnecessary bureaucracy, to increase working pleasure and to develop best

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practices’ (V22:39; translated from Dutch). Bureaucracy needs to be diminished in order to

respect professionalism and to increase work pleasure. The policy paper ‘Care with a Future’

also stresses the importance of a positive working climate.

The analysed policy documents show a plural picture of a good doctor. In order to fulfil the

requirements of the government a doctor has to perform three roles: the statesman, the

businessman and the professional. In their role as statesman doctors should take the public good

into account. As a businessman doctors have to provide demand-driven care adapted to the

wishes of the individual patient. In this role doctors are motivated by financial incentives. In

their role as professionals doctors have to be medical experts motivated by professional honour.

Performing these three roles simultaneously appears to be unfeasible. It seems to be problematic

to require doctors to live up to the standards that follow from all three roles. The ethical

dilemmas that are mentioned in the previous paragraph seem to be caused by the tension between

these three roles. Doctors are faced with a dilemma when the government requires them to act as

businessmen and as professionals simultaneously. As a businessman a doctor has to advertise his

services. However, as a professional this is less acceptable. Combining the role of a statesman

and a professional causes similar dilemmas. As a statesman a doctor is required to take the

insurance status into consideration, while this does not fit with the role as a professional. For the

medical professional guidelines require doctors to ration care on the basis of medical need. These

examples are not exhaustive, but give an impression of the problems that arise when doctors are

required to comply with all roles. It can be concluded that several standards, belonging to

different roles are summed up in the policy documents. The government seems to assume that

doctors will not live up to these standards on their own. Although sometimes doctors are

considered to be knights, for example when the government refers to professional honour, they

are mostly taken to be knaves. Hence, incentives are needed to reach the policy goals. It seems

that these incentives are aimed to result in doctors that perform the three roles at the same time.

Strikingly, the tension between the three roles is never once mentioned in the policy documents.

The ethical dilemmas discussed in this paper are ignored. In the next section the possible causes

of this important omission will be discussed.

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Why are the ethical dilemmas ignored?

The ethical dilemmas presented in this paper have never been discussed in the policy documents.

Although the implications can logically be derived from the new policy, the government never

explicitly says that doctors have to take the insurance status of their patients into consideration

and that doctors have to advertise their own services. Two characteristics of the policy

documents may have caused this lack of attention. The first feature concerns the level of analysis

in the policy papers. This paper is concerned with the medical professional ethics of doctors, but

the policy papers invariably refer to health care providers. Often no distinction is made between

the organization and managers and the doctors and other health professionals who actually

deliver care on the other. The policy documents do not elaborate on the implications of the new

system in the consulting room or the hospital floor. The use of the level of analysis may explain

why the ethical dilemmas are ignored. By using the notion of health care provider you do not

have to take the ethical implications for doctors into consideration. All requirements of the

government seem to be unproblematic on the level of the health care provider. For health care

providers are not associated with medical professional ethics. The government can require all

standards simultaneously by referring to economic terms that are not associated with medical

professionalism.

The second characteristic of the policy documents is the use of vague policy goals. The terms

that are used can mean two things simultaneously. Everybody can fill in his own meaning and

nobody can be reasonably against it: ‘For each concept, there are several plausible but

conflicting claims that can be made in the same name’ (Stone 2002:37). The case about rationing

medical care shows us the ambiguity of the notion of medical need. After the introduction of the

new health care system a member of Parliament asked the minister a question about a case in

which a patients to wait longer for a knee operation, because patients who had chosen another

insurer could benefit from the agreement between that insurer and the hospital about maximum

waiting time. The then minister of Health, Welfare and Sports (Hoogervorst) recognized the

medical criterion as a basis for rationing health care. He stated this as follows ‘The choice

between patients should be based on medical criteria’ (TK 2005-2006 25170 nr. 37; translated

from Dutch). In another letter he declared: ‘The main question is whether hospital and insurer

are allowed to make agreements about the provision of services. The main condition is that

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medical need should determine the choice between patients’ (TK 2006-2007 25170 nr 38;

translated from Dutch). However, it remains unclear what he means with medical criteria,

because he also said that ‘it should be possible to make agreements about differentiation in the

provision of services of patients’ (TK 2006-2007 25170 nr. 38; translated from Dutch). It is

unclear how these two statements can be combined in practice. Consequently, medical need

remains a vague concept with several different meanings. The answer of the Minister may imply

that a treatment is only medically necessary when you are going to die if you don’t receive

immediate care. This could mean that agreements between insurer and hospital can determine the

choice between patients in all non-life-threatening situations. However, the term medical need

might also refer to all care that is reimbursed by the health care insurance. In that case the

agreements between insurers and hospital would acquire the status of additional criteria, to be

used when two patients are equally needy. Hence simply referring to medical need does not

make clear what should be done in practice.

Both characteristics of the policy documents show the importance of the role of medical

professional organizations. Therefore, it is interesting to analyse how the KNMG reacted on the

new health care system. Did they recognize the ethical dilemmas of the new health care policy

and how did they respond to them? In the next section the reaction of the KNMG to the new

health care system will be analysed.

The reaction of the KNMG on the new health care policy

The Dutch Royal Medical Association (KNMG), founded in 1948, is a federation of six

professional organizations. The association is aimed to be a representative of the interests of

doctors. In the policy plan of 2004 the KNMG specifies their task as follows: ‘We do not

represent your income or working conditions, but focus on quality of care, professional training,

career perspectives, the health care system, legislation and medical ethics’ (KNMG 2005c:41;

translated from Dutch). Accordingly, they regularly expressed their opinion about the new health

care system during the incremental process towards managed competition.

In the beginning of the process it was unclear whether the KNMG would support the new health

care system. In a reaction to the white paper ‘Change Insured’, they reported positive as well as

14

negative aspects of the new system. They positively assessed the increased responsibility of the

actors in the health care sector but also reported shortcomings of the plan. They raised objections

to the role of the health care insurer. Insurers should not be involved in defining quality of care

according to the KNMG. The KNMG felt that health care providers and health care consumers

should assess the quality of care. They also rejected the health care insurers’ role as trustee of

their insured (K1). In the conclusion of its report the KNMG questioned the feasibility of the

new system and stressed the importance of deliberation with all actors involved. However, they

did not position themselves as either opponent or supporter of the new system (K1). The

subsequent government plan that concerned managed competition was ‘Change Insured’. In a

reaction the KNMG declared to be positive to the plan (K3).

Since 2001 the KNMG explicitly supports the new health care system. In 2001 the KNMG

declared that: ‘Health care reform is considered to be necessary’ (K4:1; translated from Dutch).

In a letter written during the 2003 formation of the government the KNMG encouraged a change

in the health care system: We need to go ahead with the healthcare reform and not revert to the

old system that did not work. Also in a difficult time of the economy the right to health care does

not stop when the year is almost over (K8:1;translated from Dutch). With this sentence the

KNMG referred to the situation in which a macro budget rationed the supply of care. During the

2007 formation of the government the KNMG confirmed their support: ‘The KNMG supports

managed competition and does not want major changes, because these may cause commotion’

(K16:1;translated from Dutch). However, their main reason for supporting the new system was

the change towards an ‘integrated system’, which abolished the distinction between Sickness

Funds and private insurers. Moreover, they approved of the duty for citizens to be insured, and

the duty of health care insurers to accept every citizen and to purchase enough care for their

insured. Furthermore, they were enthusiastic about the increasing responsibility and choices of

patients. Improvement in working conditions of doctors were also raised as a reason to support

the new system (K4:2; translated from Dutch). In addition to their positive attitude they reported

some shortcomings of the new system to the Parliament. The shortcomings were: lack of

assurance about the privacy of patients, possible limitation of free choice of doctor, a possible

split in primary care because the law did not specify primary care, danger of risk-selection due to

imperfection in the risk adjustment system and the problems of people that are not insured

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(illegal people or people who do not pay their premiums) (K11, K12, K13, K14, K15). These

objections all ask for tiny technical adjustments to the system, they do not touch the basis of the

new health care system: managed competition. Moreover, the objections are not related to the

cases discussed in this paper. However, this does not mean that the KNMG considers these cases

to be unproblematic.

Contrary to their positive attitude towards the new health care system the KNMG objects to

some initiatives resulting from the new health care system based on managed competition. The

KNMG repeatedly declares that they are against bonuses of health care insurers to influence the

prescribing behaviour of doctors. The KNMG indicates that the influence of health care insurers

is increasing and raises important objections to this development (KNMG 2005a, KNMG 2005b,

KNMG 2006a). According to the KNMG health care insurers should never decide on medical

treatments: ‘We still take the position that doctors decide on the medical treatment of patients’

(KNMG 2006a:7; translated from Dutch). Autonomy is considered to be an important feature of

professionalism and should be sustained. The KNMG also appeals to professional autonomy in

their objections to the plans of a health insurance company (Menzis) to establish their own

(commercial) primary care centres. Another reason for opposing these plans is a fear that

commercial considerations will become more important than the deliverance of high quality care

(KNMG 2006c)

Although these objections of the KNMG are not identical to the cases we discussed earlier in the

paper, the medical ethical principles that caused objections of the KNMG are comparable to the

principles discussed in the cases. The objections that are raised to bonuses rewarded by the

health insurance companies can be related to our discussion about rationing medical care on the

basis of insurance status. The health insurance companies try to influence the decision of the

doctor, either by claiming preferential treatment for their insured or by inducing doctors to

prescribe certain treatments rather than others. Both actions threaten the professional autonomy

of doctors. The objections to a commercial primary care centre are based on the conviction that

commercial interests and the provision of high quality care are hard to reconcile. This argument

echoes the arguments we raised against medical advertising. It does not seem unlikely that

KNMG would also oppose that.

16

The developments criticized by the KNMG result from the new system. However, it seems that

KNMG does not acknowledge that connection. They never mention these dangers in the letters

in which they raised objections to the new system. There is some evidence that the KNMG made

did see potential tensions between managed competition and medical professional ethics.

Inspired by an advice of its Medical Ethical Committee the KNMG planned to organize a

symposium about medical ethics and the health care market, entitled “Is there ethics in the

healthcare market?”. The symposium was aimed to discuss the fear that norms could dilute in the

new health care system. However, the symposium was cancelled due to a lack of interest among

members (KNMG 2006b). Moreover, some sentences in the documents about the new health

care system refer to medical professional values. For example in the report about demand-driven

care: ‘The decision about the provision of care remains responsibility of professionals.’ (K4:1;

translated from Dutch). However, these principles are simply mentioned. Apparently they are not

taken to be in immediate danger as a result of the new system. It seems the KNMG did

acknowledge potential tensions between professional ethics and managed competition, but

tended to deride these tensions as minimal.

The characteristics of the policy documents could be a possible explanation for this lack of

insight into the results of the new health care system. The economic language used in the policy

documents hides its effects on the relation between doctor and patient. Moreover, the vague

policy goals can be interpreted in different ways. This may have caused a blind spot about the

ethical dilemmas resulting from the new health care system.

Another possible explanation for the KNMG’s support for the health care system could be fear

that the government would have taken further actions when the medical profession would have

objected to the new plans. If this explanation is correct the ethical dilemmas were recognized,

but ignored in order to prevent worse situations. This explanation finds some support in a remark

in the KNMG report about the no-claim6 system. They state: ‘Cost containment is not popular

among doctors. (…) De KNMG chose to support some unpopular measures in order to prevent

worse measures’ (K9:7; translated from Dutch). They continue: ‘Systematically rejecting

managed care will result in a smaller basic benefit package and/or enduring deterioration of

6 This system is aimed to increase cost awareness of patients by introducing a no claim.

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working conditions of health care providers and/or increasing waiting lists.’ (K9:8; translated

from Dutch). It is interesting to notice that it is highly doubtful whether the professional

organization represents its members by its positive attitude towards the new health care system.

A questionnaire among medical specialists showed that 83% of the medical specialists opposed

the introduction of competition in health care. The chairman of the Order of Medical Specialists

(one of the member organizations of the federation KNMG) stated in an interview published in a

Dutch opinion magazine: ‘We have a lot of work to do’ (Hulshof & Verhey 2005:). Instead of

representing the voice of their members, the organisation sets out to advocate the government

plans to its members. It is hard to tell whether the chairman is motivated by a positive attitude

toward the government plans or by fear of the consequences, should he choose not to cooperate.

Conclusion

The new division of responsibilities in the Dutch health care system may have some important

implications for medical professional ethics. To illustrate this influence two medical ethical

principles that are challenged by the new health care system are discussed in this paper: doctors

ration care on the basis of medical need and doctors do not advertise their own services. In order

to understand whether the Dutch government deliberately aims at changing medical professional

ethics an overview of the characteristics of a good doctor in the policy documents is given. It

seems that the government wants to add new principles to medical professional ethics, but also

wants to protect old norms. It can be concluded that the government draws a plural picture of the

good doctor. The analysis of the authoritative policy documents shows that the government

wants doctors to perform three roles simultaneously: the statesman, the businessman and the

professional. However, it is unclear how doctors can combine these three roles. Neither the

government nor the Dutch Royal Medical Association (KNMG) discussed the ethical dilemmas

that result from this plural picture. Two characteristics of the policy documents seem to

contribute to this ignorance of ethical dilemmas. Often no distinction is made between

management and doctors. The policy documents mostly refer to health care providers. By using

this economic notion you do not have to take ethical implications for doctors into consideration.

The use of vague policy goals may also contribute to the neglect of ethical dilemmas. Ethical

dilemmas only become apparent when vague policy goals are specified.

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Annex

Year Code Title 1986 V1 Nota 2000: ontwikkelingsplan voor een gezondheidszorgbeleid tot het jaar 2000 (Note 2000: plan to

develop health care policy until 2000) 1987 V2 Bereidheid tot verandering (Willingness to Change) 1987 V3 Naar een verantwoord gezondheidsbestel (Towards an Considered Health Care System) 1988 V4 Verandering verzekerd (Change Insured) 1990 V5 Werken aan zorgvernieuwing (Working on Health Care Innovation) 1992 V6 Modernisering zorgsector. Weloverwogen verder (Modernisation Health Care Sector. A Well-

considered progress ) 1995 V7 Nota Curatieve zorg (White paper Curative Care) 2000 V8 Actieplan zorg verzekerd (Actionplan Care Insured) 2000 V9 Beweging in de zorg (Movement in Care) 2001 V10 Zorg met toekomst (Care with a Future) 2001 V11 Beleidsbrief Modernisering curatieve zorg (Policy Letter Modernisation Curative Care) 2001 V12 Vraag aan bod (Focus on Demand) 2001 V13 Met zorg kiezen (Choosing with Care) 2002 V14 Nadere uitwerking vraag aan bod (Further Explanation Choosing with Care 2004 V15 Hoofdlijnen herziening stelsel curatieve zorg (Main elements reform curative health care system) 1986 V16 Coalition agreement Lubbers 2 1989 V17 Coalition agreement Lubbers 3 1994 V18 Coalition agreement Kok 1 1998 V19 Coalition agreement Kok 2 2002 V20 Coalition agreement Balkenende 1 2003 V21 Coalition agreemeent Balkenende 2 2007 V22 Coalition agreement Balkenende 4 Table 1: overview of analysed policy documents

Year Code Title 1988 K1 Commentaar op ‘Verandering verzekerd’ (Comments on ‘Change Insured’) 1988 K2 Concurrentie in de gezondheidszorg (Competition in health care) 1990 K3 Visie van de KNMG op de nota ‘Werken aan zorgvernieuwing’ (Comments on ‘Working on Health

Care Innovation’) 2001 K4 Verankering van vraaggestuurde zorg. Standpunt van de federatie KNMG inzake de

stelselherziening. (Opinion on health care reform) 2001 K5 KNMG werkt stelselstandpunt verder uit (KNMG elaborates on opinion about health care reform) 2001 K6 Uitgangspunten en inrichting zorgstelsel. De KNMG over de inhoud, kwaliteit en sturing van de

gezondheidszorg (KNMG about content, quality and steering of health care) 2002 K7 KNMG wil het beste van twee stelsel (KNMG wants best of two systems) 2003 K8 Brief kabinetsformatie (11 februari 2003) (Letter during government formation) 2003 K9 Toegang verzekerd (uitgangspunten voor basispakket van artsenfederatie KNMG) (Access Insured) 2004 K10 Stelselherziening: no-claimregeling aanvullende verzekering en zorgtoeslag (Health care system

reform: no-claim and complementary insurance) 2005 K11 Brief Tweede Kamer: Wetsvoorstel Invoerings- en aanpassingswet Zorgverzekeringswet (22 juni

2005) (Letter to Parliament) 2005 K12 Brief aan de leden van de Vaste Kamercommissie: Zorgverzekeringswet (31 mei 2005) (Letter to

Parliament) 2005 K13 Brief aan de leden van de Vaste Kamercommissie: Ernstige gebreken in de Zorgverzekeringswet en

het Besluit zorgverzekering die gerepareerd dienen te worden (25 mei 2005) (Letter to Parliament)

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2005 K14 Brief aan de Eerste Kamer: Wetvoorstel Invoerings- en aanpassingswet Zorgverzekeringswet (22 september 2005) (Letter to Parliament)

2005 K15 Moeilijk te repareren schade voorkomen (Prevent damage of the new system) 2006 K16 Achtergondnotitie over de wensen van de KNMG voor de gezondheidspolitiek in de komende

kabinetsperiode (KNMG’s desires concerning health care policy) Table 2: overview of analysed documents of the KNMG

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